Our data shows emergency room costs have gone up by 182 percent in the last four years in Texas. What is going on in the market and what can we do to slow runaway health care costs? Dr. Vivian Ho, a health economist at Rice University's Baker Institute, Dr. Paul Hain, BCBSTX North Texas Market President, and co-host Ross Blackstone, BCBSTX Director of Strategic Influence, join Dr. McCoy for this discussion. You can listen to the complete discussion in podcast form on Apple Podcasts and SoundCloud.

Blue Promise is an online video blog that aims to address complicated health issues with candid conversations from subject matter experts. New editions are published regularly and are hosted by Dr. Dan McCoy, President of Blue Cross and Blue Shield of Texas.

Thank you Doctor, we've got a lot to get to today, we have two guests Dr. Vivian Ho is a Health Economist at Rice University's Baker Institute, thanks for being here and we have Dr. Paul Hain

He is our North Texas Market President, Blue Cross Blue Shield of Texas.

Dr. Hain let's start with you, just to talk about this claims review process to manage

the claims from emergency care, what's it all about?

PAUL:

Well really it's a soup to nuts claims review process that we are implementing for folks who are on an HMO product, who go to an out of network emergency room at which point we will hold the claims and not deny we'll hold the claim while we request medical records. We’ll take their records and make sure that actually everything on the bill matches that happened in the E.R because sometimes we find things that don't we want to make sure that our folks aren't overbilled for things and so once

we finish with that combing over the record and the bill to make sure that all of that is correct

We'll also be looking at something called the prudent layperson point of view and if we find that a member who went to that ER was not acting in a reasonable manner and an example of that might be going to get your sports physical for your kid because football practice is about to start and

really no reasonable person would think that's an emergency then we'll deny that claim because you're not covered for out of network non-emergency care on an HMO. So that's how that will work?

ROSS:

OK so we have about 5 million members at Blue Cross Blue Shield of Texas, this is only… this isn't

OK so Dr. Ho Give us some perspective of why this type of policy is needed why is

emergency care use an issue in Texas?

VIVIAN:

Well we all know how fast health care costs are growing, they're growing faster than the rate of the economy and we also know that up to 30 percent of healthcare spending is waste and there have been multiple studies that show a lot of that waste is actually in the ER space. There are people who are going to ER rooms and at least 10 percent of those visits actually could have been taken care of in less aggressive lower cost settings, so to the extent that we can move those unnecessary visits to a lower cost setting. We lower health care spending for everyone and

that helps to lower our health insurance premiums

DAN:

So, let's put this in context for just a minute because you said, grow greater than the economy, and let's put that in context because this is not just a little growth this is a significant amount of increase in cost related to health care expenses with emergency care.

VIVIAN:

Oh absolutely. You know you look at the rate of the economy growth now is, what? 2 percent at times, it inches up to 3 percent but we have health care spending at 5 percent. I haven't seen the most recent numbers on growth and emergency care spending but I know…

DAN:

Well, fortunately I have.

VIVIAN:

Wow, good.

DAN:

So I've seen those so I don't know if this is exactly comparable, but Paul, respond to this, is that

the increase in cost and emergency services in our metro areas is above 150 percent in four years.

PAUL:

So over the last four years, our spending on emergency care has gone up 182 percent.

DAN:

All comers that's not just… that's not just freestanding ERs.

PAUL:

No that's all in.

VIVIAN:

That's astounding.

PAUL:

It is astounding, and you know the interesting part is, it coincides perfectly with the rise of freestanding ERs and I don’t think that is a coincidence.

ROSS:

OK so we're going to get into freestanding ERs coming up in our next segment but first, I want to dig in a little deeper if we could, Dr. McCoy about this new policy for emergency room care for some of

our HMO members because it is getting a lot of attention in Texas media. Dr. Hain you gave us a high-level overview of how it works in the beginning of this segment.

PAUL:

Right

ROSS:

Maybe we could just get a little more clarification on some of these things, first we're

not going to be denying …

PAUL:

Correct.

ROSS:

… just off the bat

PAUL:

Correct you know and we've been asked for where’s the secret list of codes that we're not going to pay for, there's no secret list of codes, right. That's the whole reason that we request a medical record because what you want is to actually see what brought the member to the emergency room,

right?..not what the final diagnosis was and so when you can see in the medical record the entire history and the symptoms that brought the member in then you can actually assess was somebody being a reasonable person to go to the ER or was somebody just using it purely for convenience.

DAN:

So why don't you just do some kind of statistical analysis of the codes and explain a little bit

about prudent layperson versus the final diagnosis because I think that's a little bit confusing.

PAUL:

It is a little bit confusing and you know the reason I think that you were referring to statistical

analysis is that I can remember how many years ago now, but NYU published a very interesting paper

talking about certain categories of disease were not.. were overrepresented in the sample in that virtually all of the time or most of the time or more than half of the time depending on the disease

they really weren't an emergency however doing a statistical analysis like that fails at the individual level because you can't just say, well, you came out with this diagnosis therefore we know you didn't

really have an emergency, so we have to get upstream and actually look at the reason they came in and have a physician read that chart and say was this reasonable or not.

DAN:

So you actually have to look at the medical record and look at the presenting complaint?

PAUL:

Correct and the reasonable test is really would a person of average medical knowledge have

had reason to fear for a body part or life, limb that sort of thing so it's an credibly soft standard in that when you apply it correctly, in reading these charts, really it's going to come down to we're denying a visit a claim or something that everyone would look at each other and say, everybody knows that's not an emergency.

DAN:

So, it's also the prudent layperson standard, you specifically use the word reviewed by a doctor.

PAUL:

Yes.

DAN:

And the doctor is important, I guess, because the overall concept, because somebody could

present with say itchy scalp…

PAUL:

Right

DAN:

But they could be having a stroke.

PAUL:

Absolutely, so you know the whole picture of how they got there is very important and really the reason we have doctors reviewing that is that we are convinced that to really read a medical record you need to be a physician and so we have physicians reading the medical records to understand what was happening to bring that person in.

DAN:

So to Ross’s point, this has gotten in the news a lot but this is not that big of a part of this emergency benefit management approach.

PAUL:

Correct, I think it got in the news a bit because it's kind of the scare tactic out there about the policy but really the vast majority of the policy and the procedures are, we know that there…we find a lot of errors in the bills call it fraud, waste or abuse however you want to discuss it. We know we find a lot of errors in the billing when we compare the bills and the medical records from the out-of-network ERs.

DAN:

And so you're not saying necessarily that… Necessarily that people are being intentional about the billing but there are certainly discrepancies. Give me an example.

PAUL:

So, say we see a CAT scan billed on the bill and you know you're there for strep throat and then

we go and read the medical record and you went and you got a throat swab and you were

diagnosed with strep throat and you got an injection of penicillin and you went home. Well there is no mention of ever doing a CAT scan, yet, we were billed for a CAT scan. So that would be something

that we could then cross off the bill and say well because there was no CAT scan, we're not paying

for a CAT scan.

DAN:

and neither should the consumer.

PAUL:

Right and it actually… that actually protects our members because oftentimes they owe a

percentage of the total bill. So if there is a very expensive CAT scan on the bill that never really

happened, they would be showing a percentage of that very expensive CAT scan and now they aren't.

DAN:

So like coinsurance?

PAUL:

Absolutely.

ROSS:

So, I'm the only one on this panel who is not a doctor. Dr. McCoy, you use the term

“presenting”, I think most people in your community know what that word means but I just like to clarify for the layperson that someone who may not even be prudent, “presenting” means what I am

coming to you saying this is the problem that I'm having. so if I'm having a sharp pain in my

stomach and I can't stand up straight, that's what I'm “presenting” now that could be gas or it

could be appendicitis that's what, you as doctors figure out. But I'm “presenting” a sharp pain in my stomach.

DAN:

We call it the “chief complaint”, so when you present, you usually present with a chief complain.

Physicians are trained to capture that in the form of a quote, usually like a pain in throat or sometimes people say I think I have strep throat, that's their chief complaint, right? But back to this presentation, I think it's important because there are certain people that arrive in the ER that don't really have a chief complaint. They come by an ambulance or so how does this policy work in that?

PAUL:

Well certainly…we think that you're being a prudent person if you're in an ambulance and are being delivered to an emergency room, that's obviously a covered benefit. So if you're referred to an

emergency room by a healthcare professional, we think that you should go to an emergency room, so all of those things are covered without…

DAN:

So, if you call your doctor and you get that recording and it says, you think you have an emergency…

PAUL:

Yeah

DAN:

Explain… walk me through that.

PAUL:

So if you get a recording, if you think you’re having an emergency, really that's not advice to go to the ER, right? that's if you think… that's the same advice we give everyone if you have an emergency

you should go to the E.R…

However, if you're on your phone with your doctor or if you're in your doctor's office and you are told

Hey we think something bad may be happening, you should go to the E.R. that's.. you’re very prudent

to go to the E.R..

DAN:

So, I think the end of the statement of concern here is, should people be afraid to go to the emergency room if they have an emergency?

PAUL:

Oh absolutely not and that..you hear folks talking about, oh people are going to be scared to go to the emergency room now because they're going to be worried they're going to get a bill and what we're trying to explain to folks is really, if you think you’re having an emergency, that's always covered because the only thing we're looking for is when people knowingly show up for convenience

Care, right? So that's completely different from actually thinking you have an emergency situation.

DAN:

OK so somebody reached out on social media to me and they said people are going to get turned

away from the emergency room if they have an emergency, somebody could get turned away if they have a heart attack, is that is that true?

PAUL:

No absolutely not, there are very strict laws in place. There's something called EMTALA

that require all emergency rooms to screen for a medical condition, an emergency medical condition

every time you present to an emergency room, moreover, right now, we know that when uninsured folks present to emergency rooms, they're treated, so I don't see how you can make the logical leap that just because if you show up for convenience, there might not be payment, that an emergency room will suddenly turn you away when you're having a heart attack.

ROSS:

Doctor Ho, I saw you shaking your head when they were talking about some of these kind of scare tactics, why? What's behind all of that, why do you think that people are trying to maybe stop this kind of cost management when it seems like it's a good thing?

VIVIAN:

Well I think, unfortunately, a policy like this that makes a lot of sense is going to affect the growth of freestanding emergency rooms, which are not in hospitals, they are located in local strip malls and consumers often confuse them for being a retail clinic or an urgent care clinic and they don't realize there's a huge difference in expense and this type of action is meant to discourage

people from thinking, oh well you know, I have a strep throat or I've got a fever and since this

place is so close to home, this is where I'm going to go for my care. And that's the unnecessary

expenditures that we just can't have in the healthcare system, if we're going to try and slow

the cost growth.

ROSS:

Well that's a perfect setup for our next segment, Dr. McCoy. Coming up, we're going to talk a

little bit more about freestanding ERs. Before we wrap things up here though I just want to say that

Dr. Hain, correct me if I'm wrong, if people do get a claim that is denied from an emergency room they do have the right to appeal it?

PAUL:

Absolutely, everyone retains all of their normal appeal rights so if we deny your claim for not meeting

prudent layperson standard and you disagree, you are very able to feed us more information. You can appeal that claim and we will re-adjudicate it.

ROSS:

And there is a new website, SMART E.R. CARE TEXAS dot com, that people could go to for

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